NEUROLOGY + NEUROSURGERY

ResponseVITAMIN-D a mnemonic to remember
Vascular (Stroke)
Infection (meningitis, cerebral abscess)
Trauma
AV malformations
Metabolic (Hypoglycaemia, Hypo/hypernatraemia, hypocalcaemia)
Idiopathic
Neoplasm (SOL)
Drugs - intoxication (Sympathomimetics, antipsychotics, antidepressant, isonazid, opioids) + withdrawal (Alcohol, benzos, barbituates)
ECLAMPSIA in female of child bearing age
Hypoxic seizure
Medication non compliance/dosage changes

ResponseCardiac
Arrhythmia
Vasovagal
Seizure disorder (epilepsy)

• Prior history of epilepsy, aura, - Antiepileptics

Trauma - head injury
CNS infection - meningitis

• Meningisim, neck stiffness, patechial rash with DIC, headache. LP - white cells - IV antibiotics (ceftriaxone 2g +/-vancomycin 30 mg/kg) IV fluids, ICU

Intracranial - CNS bleed, SOL, thromboembolic stroke
Metabolic - High/Low BSL, High/Low Sodium, low calcium (renal/hepatic failure)
Drugs - intoxication - EtOH, anticholinergics, sympathomimetics (Amphetamine, cocaine, ice), organophosphates

• Sympathomimetic toxidrome dilated pupils, amphetamine use, track marks - supportive care with benzos, cooling +/- intubation
• Serotonin toxicity - MDMA use, dilated pupils, hypertonia + hyperreflexia. Supportive care
• NMS - rigidity, hypertension

Drug withdrawal - EtOH, Benzos, Opioids, Cocaine, anticonvulsants
Pseudoseizure (non epileptiform seizure)
Heat stroke

• Hot environment, use of drugs that predispose, activity (marathon) - Supportive, cooling +/- intubation with paralysis if severe

Hyperthyroid
Electrocution (read stem if risk)
Eclampsia

ResponseAnalgesia
Tramadol
Lignocaine
Salicylates

Antimicrobials
Isoniazid
Chloroquine
Quinine

Psychiatric meds
Citalopram
Lithium
Venlafaxine
TCA’s
Antidopaminergic agents

Others
Hypoglycemics
Essential oils
baclofen
List is VAST - lots more

ResponsePost ictal confusion (most sensitive 94%, 68% specific)
Observed head turning (most specific 97%)
Unusual posturing
Observed limb jerking 69% sensative, 88% specific)
Lateral tongue biting (Tip of tongue possible in syncope)
Urinary incontinence - not that good

Past history of seizures
Time course - sudden onset/offset, brief, usually <2mins
Amnesia

ResponseBGL ? hypoglycaemia
ECG - features of sodium chanel blockade, prolonged QT
Blood gas - Hypontaraemia/tox picture

ResponseFocal abnormality on neurolgic examination
Malignancy/Neurocutaneous disorder/Known intracranial pathology (Eg aneurysm)
Closed head injury/Trauma from fall/related to seizure
Focal onset of seizures
Unexplained seizure activity in ED or seizure >15 mins
Absence of a history of alcohol abuse
Altered mental status
>65
Seizure >15 mins
Bleeding disorder

ResponseNo indications for admission (no more seizures, no treatment for underlying cause)
Stable, conscious
Daylight
Support at home
Follow up organised
Safety discussed - Driving, working with machinery etc.

ResponseMidazolam 5mg aloqots IV
eTG:
Phenytoin 20 mg/kg IV over 30 mins
Levetiracetam 60 mg/kg Adult, 40 mg/kg paed (1-2g IV common)
Valproate ~40 mg/kg (1-1.5g common)
Phenobarbitone 10-20 mg/kg
Propofol (needs airway protection)
Pyridoxine (Vitamin B6) 5g or 70 mg/kg (refractory seizure in neonates - B6 deficiency - Definately not first line for anything)

ResponseHypoxic brain injury/cerebral oedema
Intracranial haemorrhage
Pulmonary oedema
Rhabdomyolysis/renal failure
Non head trauma - eg: Spine fracture (Posterior shoulder dislocation probably better)

ResponseEffect
Sodium channel blockade

• QRS widening
• Dysrhythmia including VT

Management

• Sodium bicarbonate 2mmol/kg IV every 1-2 mins
• Lignocaine 1.5mg/kg (Once pH >7.5)

ResponseDiazepam - prevention of withdrawal seizures. 5-20 mg Q2h for withdrawal according to AWS
Oxazepam - prevention of withdrawal seizures in liver failure 15-30 mg Q2H as above
Midazolam - treatment of seizures - 5-10 mg IV/IM bolus
Diazepam - treatment of seizure 5-10 mg IV/IM bolus
RSI + Prop/thiopentone - status 2nd line after benzo’s
?Keppra as 3rd line 60 mg/kg
Thiamine prevention of Wernicke's encephalopathy 300 mg IV/IM TDS

ResponseEpisodes >5 mins
Asynchronous with a stop start quality
Paradoxically worse with pharmacotherapy
No change in serum lactate
Lack of physiological changes (eg: tachycardia/hypoxia)
Generalised seizure activity with normal awareness

ResponseAtypical seizure like movements such as back arching, thrashing, side to side head movements
Yelling
Pelvic thrusting
Eye closure
Whispering
Crying
Lack of post ictal deep breathing

ResponseFemale
History of abuse
PTSD
Personality traits
Previous poor doctor-patient relationship